Fillable I-102 General Form And Instructions (ILW.COM)

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I-102 General Form And Instructions (ILW.COM)

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Department of Homeland Security
U.S. Citizenship and Immigration Services
OMB No. 1615-0079; Expires 09/30/10
Part 1. Information About You
Part 2. Reason for Application
I am applying to replace my lost or stolen Form I-94 (or I-94W).
I am applying to replace my lost or stolen Form I-95.
I am applying to replace Form I-94 (or I-94W) because it is mutilated. I have
attached my original I-94 (or I-94W).
I am applying to replace Form I-95 because it is mutilated. I have attached my
original Form I-95.
I was not issued Form I-94 when I entered as a nonimmigrant, and I am filing
this application together with an application for an extension of stay/change of
status.
START HERE - Please type or print in black ink.
I-102, Application for Replacement/Initial
Nonimmigrant Arrival - Departure Document
Form I-102 (Rev. 01/13/10)Y
Returned
Date
Date
Date
Date
Date
Date
Date
Date
Resubmitted
Reloc Sent
Reloc Rec'd
Applicant
Interviewed
on
Receipt
Remarks
Action Block
Attorney or Representative, if any.
To Be Completed by
Fill in box if G-28 is attached
to represent the applicant.
ATTY State License #
For USCIS Use Only
New I-94 #
Family Name
Given Name
Middle Name
Apt./Suite #
City
State
Street Number and Name
In care of -
Country
Zip/Postal Code
Address - In care of -
Country of Birth
Country of Citizenship/Nationality
Date of Birth (mm/dd/yyyy)
A-Number (If any)
U.S. Social Security # (If any)
Date (mm/dd/yyyy) and Place of Last Admission
I-94, I-94W, or I-95 Arrival/Departure Document #
Status Expires on (mm/dd/yyyy)
Current Nonimmigrant Status
Check the box that best describes your reason for requesting a replacement document
(Check one box).
I was not issued Form I-94 when I entered as a nonimmigrant member of the
military, and I am filing this application for an initial Form I-94.
I was issued Form I-94, I-94W, or I-95 with incorrect information, and I am
requesting USCIS to correct the document. I have attached my original Form
I-94, I-94W, or I-95.
I declare that I prepared this application at the request of the above person, and it is based on all information of which I have
knowledge.
Form I-102 (Rev. 01/13/10)Y Page 2
Part 5. Signature of Person Preparing Form, if Other Than Above (Sign below)
I certify, under penalty of perjury under the laws of the United States of America, that this application and the evidence submitted
with it is all true and correct. I authorize the release of any information from my records that U.S. Citizenship and Immigration
Services needs to determine eligibility for the benefit I am seeking.
Firm Name
Signature
Part 4. Signature (Read the information on penalties in the instructions before completing this section. You must file this
application while in the United States.)
2. Are you now in removal proceedings?
Part 3. Processing Information
1. Are you filing this application with any other petition or application?
No
Yes - Form #
Class of Admission
Place of Admission
Your name exactly as it appears on Form I-94, I-94W, or I-95, if known (Print clearly)
No
Yes (Give detailed information regarding the proceedings. If you need more space to complete the answer, use a
separate sheet(s) of paper. Write your name and A #, if any, and "Part 3, Number 2" at the top of each sheet.)
Daytime Telephone Number (With area code)
E-Mail Address (If any)
Date (mm/dd/yyyy)
Print or Type Your Name
Firm Address (Street Number and Name or P.O. Box, City, State, Zip Code)
Signature
Date (mm/dd/yyyy)
Daytime Telephone Number (With area code)
3. If you are unable to provide the original of your Form I-94, I-94W, or I-95, give the following information:
(
)
(
)
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I-102 General Form And Instructions (ILW.COM)

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Completed 9 January 2021

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